GM case


 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

A 52 year old male shopkeeper by occupation  presented to OPD with the chief complaints of decreased urine output, irregular bowels and micturition, from past 6 months, he has swollen

 left hand  since 4 months(left arm AV fistula access)

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 6 months back then he observed the decreased urine output, burning micturition, irregular bowels,loss of appetite for one month

6months back he consulted a doctor at Hyderabad he had a x ray of the kidneys and the patient was advised to go for the dialysis.

Initially he started dialysis at Hyderabad later he visited kamineni for the dialysis which is his 5th dialysis in the kamineni.

PAST HISTORY

Hypertension since 6 months 

Not known case of CAD/TB/DM/EPILEPSY/ASTHMA/thyroid disorders

No history of surgeries or blood transfusions in the past

PERSONAL HISTORY

mixed diet

Appetite is decreased due to dialysis

Irregular bowel and bladder moments

Normal sleep

No addictions


FAMILY HISTORY

There are no similar complaints in the his family

No cancer deaths in the family



TREATMENT HISTORY

The patient is not allergic to any known drugs


GENERAL EXAMINATION:

On examination the patient is conscious, coherent, cooperative

No icterus and pedal edema

No pallor

Clubbing is not seen

No cyanosis and lymphadenopathy


VITALS:

Temperature : afebrile

Pulse rate :84/min

Respiratory rate:24/min

BP:170/100

SPO2 at room air :98%

GRBS :36mg%


SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM:

S1 and S2 sounds are heard, No murmurs


RESPIRATORY SYSTEM

Dyspnoea : No

Wheeze : No

Position of trachea : central

Breath sounds : vesicular


PER ABDOMEN

Abdomen is soft and non tender

Bowel sounds heard

No palpable mass or free fluid


CENTRAL NERVOUS SYSTEM:

Patient is conscious

Speech : normal

No signs of meningeal irritation

Reflexes : present

Cranial nerves : intact


INVESTIGATIONS:





PROVISIONAL DIAGNOSIS:
Chronic kidney disease?

FINAL DIAGNOSIS:
chronic kidney disease with k/c/o hypertension

TREATMENT:
Fluid retention less than 1.5lit/day
Salt retention less than 2g/day
Tab lasix 40mg
TAB nicardia 20mg
TAB Nodosis 500mg
TAB shelcal
TAB bio-D3 0.25mg
INJ: erythropoietin 400/IUSC weekly once.




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